Arthur A. Stone

Subjective wellbeing, health, and ageing

Subjective wellbeing and health are closely linked to age. Three aspects of subjective wellbeing can be distinguished-evaluative wellbeing (or life satisfaction), hedonic wellbeing (feelings of happiness, sadness, anger, stress, and pain), and eudemonic wellbeing (sense of purpose and meaning in life). We review recent advances in the specialty of psychological wellbeing, and present new analyses about the pattern of wellbeing across ages and the association between wellbeing and survival at older ages. The Gallup World Poll, a continuing survey in more than 160 countries, shows a U-shaped relation between evaluative wellbeing and age in high-income, English speaking countries, with the lowest levels of wellbeing in ages 45-54 years. But this pattern is not universal. For example, respondents from the former Soviet Union and eastern Europe show a large progressive reduction in wellbeing with age, respondents from Latin America also shows decreased wellbeing with age, whereas wellbeing in sub-Saharan Africa shows little change with age. The relation between physical health and subjective wellbeing is bidirectional. Older people with illnesses such as coronary heart disease, arthritis, and chronic lung disease show both increased levels of depressed mood and impaired hedonic and eudemonic wellbeing. Wellbeing might also have a protective role in health maintenance. In an analysis of the English Longitudinal Study of Ageing, we identify that eudemonic wellbeing is associated with increased survival; 29·3% of people in the lowest wellbeing quartile died during the average follow-up period of 8·5 years compared with 9·3% of those in the highest quartile. Associations were independent of age, sex, demographic factors, and baseline mental and physical health. We conclude that the wellbeing of elderly people is an important objective for both economic and health policy. Present psychological and economic theories do not adequately account for the variations in patterns of wellbeing with age across different parts of the world. The apparent association between wellbeing and survival is consistent with a protective role of high wellbeing, but alternative explanations cannot be ruled out at this stage.

PROMIS measures of pain, fatigue, negative affect, physical function, and social function demonstrated clinical validity across a range of chronic conditions

OBJECTIVEnTo present an overview of a series of studies in which the clinical validity of the National Institutes of Healths Patient Reported Outcome Measurement Information System (NIH; PROMIS) measures was evaluated, by domain, across six clinical populations.nnnSTUDY DESIGN AND SETTINGnApproximately 1,500 individuals at baseline and 1,300 at follow-up completed PROMIS measures. The analyses reported in this issue were conducted post hoc, pooling data across six previous studies, and accommodating the different designs of the six, within-condition, parent studies. Changes in T-scores, standardized response means, and effect sizes were calculated in each study. When a parent study design allowed, known groups validity was calculated using a linear mixed model.nnnRESULTSnThe results provide substantial support for the clinical validity of nine PROMIS measures in a range of chronic conditions.nnnCONCLUSIONnThe cross-condition focus of the analyses provided a unique and multifaceted perspective on how PROMIS measures function in real-world clinical settings and provides external anchors that can support comparative effectiveness research. The current body of clinical validity evidence for the nine PROMIS measures indicates the success of NIH PROMIS in developing measures that are effective across a range of chronic conditions.

PROMIS Fatigue Item Bank had Clinical Validity across Diverse Chronic Conditions

OBJECTIVEnTo evaluate the comparability and responsiveness of Patient-Reported Outcomes Measurement Information System (PROMIS) fatigue item bank across six chronic conditions.nnnSTUDY DESIGN AND SETTINGnIndividuals (nxa0=xa01,430) with chronic obstructive pulmonary disease (nxa0=xa0125), chronic heart failure (nxa0=xa060), chronic back pain (nxa0=xa0218), major depressive disorder (nxa0=xa0196), rheumatoid arthritis (nxa0=xa0521), and cancer (nxa0=xa0310) completed assessments from the PROMIS fatigue item bank at baseline and a clinically relevant follow-up. The cancer and arthritis samples were followed in observational studies; the other four groups were enrolled immediately before a planned clinical intervention. All participants completed global ratings of change at follow-up. Linear mixed-effects models and standardized response means were estimated to examine clinical validity and responsiveness to change.nnnRESULTSnAll patient groups reported more fatigue than the general population (rangexa0=xa00.2-1.29 standard deviation worse). The four clinical groups with pretreatment baseline data experienced significant improvement in fatigue at follow-up (effect size rangexa0=xa00.25-0.91). Individuals reporting better overall health usually experienced larger fatigue changes than those reporting worse overall health.nnnCONCLUSIONnThe results support the PROMIS fatigue measuress responsiveness to change in six different chronic conditions. In addition, these results support the ability of the PROMIS fatigue measures to compare differences in fatigue across a range of chronic conditions, thereby enabling comparative effectiveness research.

PROMIS fatigue, pain intensity, pain interference, pain behavior, physical function, depression, anxiety, and anger scales demonstrate ecological validity

OBJECTIVESnEcological validity refers to the degree to which instruments faithfully capture information in respondents natural environments. We examined the ecological validity of eight instruments from the Patient Reported Outcomes Measurement Information System (PROMIS), most of which use 7-day reporting periods, by comparing PROMIS scores with daily diary data as a standard.nnnSTUDY DESIGN AND SETTINGnFive groups of approximately 100 respondents each completed daily diaries and weekly PROMIS instruments for 4 consecutive weeks: community residents; osteoarthritis patients; women experiencing premenstrual syndrome; men undergoing hernia surgery; and breast cancer patients receiving chemotherapy. The last three groups experienced events (menses, surgery, or chemotherapy, respectively) at standardized times in the protocol to examine symptom changes attributable to these events.nnnRESULTSnWe examined the ability of the PROMIS scales to replicate between-group differences in diaries, to replicate week-to-week changes in diaries, and the correlation between diary and PROMIS scales. As a secondary aim, we examined known-group differences with the PROMIS measures. All three types of ecological validity were strongly confirmed, as was known-group validity for the PROMIS recall scales.nnnCONCLUSIONnThis study adds to the growing literature supporting the reliability and validity of the family of PROMIS instruments.

Progress in measuring subjective well-being

Moving toward national indicators and policy evaluations Progress in science requires new tools for measuring phenomena previously believed unmeasurable, as well as conceptual frameworks for interpreting such measurements. There has been much progress on both fronts in the measurement of subjective well-being (SWB), which “refers to how people experience and evaluate their lives and specific domains and activities in their lives” (1). In 2009, the Sarkozy Commission recommended adding SWB measures as supplements to existing indicators of societal progress such as gross domestic product (GDP). In light of subsequent activity by governments and international organizations, we summarize several important advances and highlight key remaining methodological challenges that must be addressed to develop a credible national indicator of SWB and to incorporate SWB into official statistics and policy decisions.

Health-related quality of life measurement in oncology: Advances and opportunities

The concept of health-related quality of life has a long history in the field of oncology treatment and research. We present a brief history of how the concept has evolved in oncology and the sentinel events in that process. We then focus on advances in measurement science as applied to health-related quality of life measures and argue that a compelling new set of measurement tools is now available, including brief, generic measures with good psychometric qualities (exemplified by the new PROMIS measures and the possibility of a common metric spanning all diseases). The last section of the paper turns to emerging opportunities for these measures, including in clinical trials, healthcare reform, and regulatory deliberations. Our conclusion is that health-related quality of life is more important today than it has ever been, and that the time has come for an even wider adoption of the new measures.

Ambulatory and diary methods can facilitate the measurement of patient-reported outcomes

PurposeAmbulatory and diary methods of self-reported symptoms and well-being have received increasing interest in recent years. These methods are a valuable addition to traditional strategies for the assessment of patient-reported outcomes (PROs) in that they capture patients’ recent symptom experiences repeatedly in their natural environments. In this article, we review ways that incorporating diary methods into PRO measurement can facilitate research on quality of life.MethodsSeveral diary methods are currently available, and they include “real-time” (Ecological Momentary Assessment) and “near-real-time” (end-of-day assessments, Day Reconstruction Method) formats. We identify the key benefits of these methods for PRO research.Results(1) In validity testing, diary assessments can serve as a standard for evaluating the ecological validity and for identifying recall biases of PRO instruments with longer-term recall formats. (2) In research and clinical settings, diaries have the ability to closely capture variations and dynamic changes in quality of life that are difficult or not possible to obtain from traditional PRO assessments. (3) In test construction, repeated diary assessments can expand understanding of the measurement characteristics (e.g., reliability, dimensionality) of PROs in that parameters for differences between people can be compared with those for variation within people.ConclusionsDiary assessment strategies can enrich the repertoire of PRO assessment tools and enhance the measurement of patients’ quality of life.

Understanding context effects for a measure of life evaluation: how responses matter

We study context effects on responses to wellbeing questions. We find that those who were randomized into being asked a series of political questions subsequently report lower life evaluation; those who were previously asked about their evaluation of the direction of the United States lowered their own life evaluation, but only if they disapproved of the way the country was going. Subgroups of the population are affected in different ways; the age profile of wellbeing is tipped in favor of the elderly, and African American’s life evaluations are increased when they are asked about President Obama’s performance. The context effects are large, not easily removed, and change wellbeing rankings across groups.

Mixed emotions across the adult life span in the United States.

Mixed emotions involve the co-occurrence of positive and negative affect, such that people feel happy and sad at the same time. The purpose of the present study was to investigate age-related differences in the experience of mixed emotions across the adult life span in 2 nationally representative samples of U.S. residents. Data collected by the Princeton Affect and Time Survey (PATS, n = 3,948) and by the 2010 Wellbeing Module of the American Time Use Survey (ATUS, n = 12,828) were analyzed. In both surveys, respondents (aged 15 years or older) provided a detailed time diary about the preceding day and rated their happiness and sadness for 3 of the days episodes. From these reports, 3 different indices of mixed emotions were derived. Results indicated small, but robust, increases in mixed emotions with age. Linear age increases were consistently evident in both PATS and ATUS, and replicated across the different indices of mixed emotions. There was no significant evidence for curvilinear age trends in either study. Several sociodemographic factors that could plausibly explain age-differences in mixed emotions (e.g., retirement, disability) did not alter the age-effects. The present study adds to the growing literature documenting vital changes in the complexity of emotional experience over the life span.

Distinguishing between frequency and intensity of health-related symptoms from diary assessments

OBJECTIVEnThis study investigated the utility of distinguishing between the frequency and intensity of self-reported symptoms using diary-based assessments in a representative sample of U.S. residents.nnnMETHODSnData from the 2010 American Time Use Survey were analyzed, in which 12,000 respondents provided a diary about the prior day and rated their pain, tiredness, stress, and sadness for three of the days episodes. A two-part latent variable modeling strategy was applied to estimate the frequency (propensity of its presence) and intensity (mean level when present) of each symptom from the diary ratings. Regression analyses comparing differences in symptom frequency and intensity across demographic factors (gender, age, income, education) were conducted to evaluate the utility of the distinction.nnnRESULTSnFrequency and intensity measures were reliably estimated from 3 daily episodes, were moderately intercorrelated for each symptom domain (rs .39 to .60), and were differentially associated with demographic factors. Gender differences were evident only in symptom intensity, not frequency, with women reporting more intense symptoms. Comparisons by age showed pronounced declines in the frequency of tiredness and stress in older age, with no age-differences in the intensity of these symptoms. Higher socioeconomic status was associated with a lower intensity of pain, tiredness, stress, and sadness, but a higher frequency of tiredness and stress.nnnCONCLUSIONnA useful distinction between symptom frequency and intensity may be made from diary-based assessments. It reveals demographic differences that are otherwise obscured and enables a more detailed characterization of health-related experiences in peoples daily life.